Psychometric Characteristics of the Insomnia Severity Index in Veterans With History of Traumatic Brain Injury

Psychometric Evaluation of the Insomnia Severity Index in U.S. College Students

Psychometric properties of the Insomnia Severity Index (ISI) were analyzed in U.S. college samples. ISI items and total score with sleep and psychosocial questionnaires were examined in Experiment I. ISI diagnostic accuracy in a clinical sample with and without insomnia was assessed in Experiment II. ISI test-retest validity, confirmatory factor analysis (CFA), and item response theory via graded response model (GRM) were assessed in Experiment III. Results indicated analogous ISI and sleep diary items showed moderate correlations (r1 = .40; r2 = .45). The ISI total had weak to strong correlations with other indicators of sleep-related disturbance (rs = .25-.62). The ISI had weak to moderate correlations with psychosocial measures commonly associated with insomnia (rs = .10-.57). The diagnostic accuracy of the ISI was very high (area under the curve [AUC] = .999). Sensitivity and specificity were maximized at a cutoff score ≥ 8. The ISI demonstrated good test-retest reliability (ICC = .87). CFA revealed a three-factor model for two study samples and GRM indicated better ability of the ISI to assess moderate (Sample III) and moderate to high (Sample I) levels of insomnia severity. The ISI demonstrated good psychometric properties and appears generally valid for screening insomnia disorder and assessing insomnia severity in college students. Overlap with psychological symptoms suggests caution while interpreting these constructs independently.

Traumatic brain injury and sleep in military and veteran populations: A literature review

BACKGROUND

Traumatic brain injury (TBI) is a hallmark of wartime injury and is related to numerous sleep wake disorders (SWD), which persist long term in veterans. Current knowledge gaps in pathophysiology have hindered advances in diagnosis and treatment.

OBJECTIVE

We reviewed TBI SWD pathophysiology, comorbidities, diagnosis and treatment that have emerged over the past two decades.

METHODS

We conducted a literature review of English language publications evaluating sleep disorders (obstructive sleep apnea, insomnia, hypersomnia, parasomnias, restless legs syndrome and periodic limb movement disorder) and TBI published since 2000. We excluded studies that were not specifically evaluating TBI populations.

RESULTS

Highlighted areas of interest and knowledge gaps were identified in TBI pathophysiology and mechanisms of sleep disruption, a comparison of TBI SWD and post-traumatic stress disorder SWD. The role of TBI and glymphatic biomarkers and management strategies for TBI SWD will also be discussed.

CONCLUSION

Our understanding of the pathophysiologic underpinnings of TBI and sleep health, particularly at the basic science level, is limited. Developing an understanding of biomarkers, neuroimaging, and mixed-methods research in comorbid TBI SWD holds the greatest promise to advance our ability to diagnose and monitor response to therapy in this vulnerable population.

Psychometric Evaluation of the Insomnia Severity Index in Nurses

OBJECTIVES

Examine psychometric properties of the Insomnia Severity Index (ISI) in a sample of nurses.

METHOD

In a sample of day shift nurses (N = 289), a confirmatory factor analysis (CFA), convergent and discriminant validity analyses, and a test-retest reliability analysis were performed.

RESULTS

CFA showed that a two-factor model provided the best fit. The ISI had moderate to poor convergent validity with sleep diary parameters, and moderate convergent validity with the Sleep Condition Indicator (r = -.66), Pittsburgh Sleep Quality Index (r = .66), and PROMIS Sleep-Related Impairment measure (r = .67). The ISI demonstrated good discriminant validity with the measures Composite Scale of Morningness (r = -.27), Nightmares Disorder Index (r = .25), PTSD Checklist for DSM-5 (sleep items removed; r = .32), and Perceived Stress Scale (r = .43). The ISI had weaker discriminant validity with the PHQ-9 (r = .69) and Generalized Anxiety Disorder Screener (r = .51). The ISI demonstrated a good test-retest reliability (ICCs = .74-.88).

CONCLUSIONS

The ISI is a psychometrically strong measure for the assessment of insomnia severity in day shift nurses. Overlap with psychological symptoms, primarily anxiety and depression, suggests caution while interpreting these constructs.

Can people with poststroke insomnia benefit from blended cognitive behavioral therapy? A single case experimental design

PURPOSE

Sleep is essential for our overall health and wellbeing. Unfortunately, stroke often induces insomnia, which has been shown to impede rehabilitation and recovery of function. Cognitive behavioral therapy for insomnia (CBT-I) is the treatment of choice for insomnia in the general population and is efficacious both when delivered face-to-face or online. The primary aim of this study was to evaluate efficacy of blended CBT-I (eCBT-I) in five poststroke participants with insomnia according to DSM-5 criteria.

METHODS

A randomized multiple baseline design was used to evaluate improvements in total sleep time, sleep onset latency, sleep efficiency, nocturnal awakenings and sleep quality. The intervention included six weeks of eCBT-I combined with two face-to-face sessions.

RESULTS

All participants completed the intervention. One participant stopped using the diary, while the other four completed it fully. All five sleep diary measures improved, significantly so for nocturnal awakenings. Moreover, after completion of the treatment, four out of five participants no longer fulfilled DSM-5 criteria for insomnia disorder.

CONCLUSIONS

This is the first study to show that blended CBT-I is potentially effective in participants with post-stroke insomnia. The findings justify extension to a randomized controlled trial.

Identifying Unique Symptom Groups Following Mild Traumatic Brain Injury Using the Neurobehavioral Symptom Inventory and PTSD Checklist-5 in Military Personnel: A Bifactor Analysis

OBJECTIVE

To identify both shared and unique groups of posttraumatic stress and postconcussive symptoms using bifactor analysis.

SETTING

Two large military outpatient traumatic brain injury (TBI) rehabilitation clinics in the Southwestern United States.

PARTICIPANTS

A sample of 1476 Active Duty Service Members seeking treatment for a mild TBI sustained more than 30 days previously, without history of moderate or severe TBI, who completed measures of postconcussive and posttraumatic stress symptoms assessed at clinic intake.

DESIGN

Observational, correlational study with data taken from an institutional review board-approved clinical registry study.

MAIN MEASURES

Neurobehavioral Symptom Inventory (NSI) and Posttraumatic Stress Disorder (PTSD) Checklist for Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) ( DSM-V ) (PCL-5). Concurrent measures were Patient Health Questionnaire (PHQ-8), Pittsburgh Sleep Quality Index (PSQI), and Headache Impact Test (HIT-6).

RESULTS

Results identified a bifactor model demonstrating unique posttraumatic stress, depressive, cognitive, and neurological/somatic symptom groups that were still evident after accounting for a universal factor representing general distress. These symptom groups were differentially related to concurrently measured clinical outcomes.

CONCLUSION

Use of a bifactor structure may help derive clinically useful signals from self-reported symptoms among Active Duty Service Members seeking outpatient treatment for mild TBI.

Depression, Insomnia, and Obesity Among Post-9/11 Veterans: Eating Pathology as a Distinct Health Risk Behavior

INTRODUCTION

Understanding the interrelationships between co-occurring chronic health conditions and health behaviors is critical to developing interventions to successfully change multiple health behaviors and related comorbidities. The objective of the present study was to examine the effects of depression, insomnia, and their co-occurrence on risk of obesity and to examine the role of health risk behaviors as potential confounders of these relationships with an emphasis on eating pathologies.

METHODS

Iraq and Afghanistan conflict era veterans (n = 1,094, 51.2% women) who participated in the Women Veterans Cohort Study between July 2014 and September 2019 were categorized as having depression, insomnia, both, or neither condition. Logistic regression models were used to examine group differences in the risk of obesity. Health risk behaviors (i.e., eating pathology, physical activity, smoking, and hazardous drinking) were then assessed as potential confounders of the effects of depression and insomnia on the likelihood of obesity.

RESULTS

Obesity was most prevalent in individuals with co-occurring insomnia and depression (53.2%), followed by depression only (44.6%), insomnia only (38.5%), and neither condition (30.1%). Importantly, maladaptive eating behaviors confounded the depression-obesity association but not the insomnia-obesity association. There was no evidence that insufficient physical activity, smoking, or hazardous drinking confounded the effects of insomnia or depression on obesity.

CONCLUSIONS

These findings exemplify the complex relationships between multiple health conditions and behaviors that contribute to obesity. Elucidating these associations can enhance the precision with which interventions are tailored to efficiently allocate resources and reduce the severe health impact of obesity among veterans.

The simplification of the insomnia severity index and epworth sleepiness scale using machine learning models

Insomnia and excessive daytime sleepiness (EDS) are the most common complaints in sleep clinics, and the cost of healthcare services associated with them have also increased significantly. Though the brief questionnaires such as the Insomnia Severity Index (ISI) and Epworth Sleepiness Scale (ESS) can be useful to assess insomnia and EDS, there are some limitations to apply for large numbers of patients. As the researches using the Internet of Things technology become more common, the need for the simplification of sleep questionnaires has been also growing. We aimed to simplify ISI and ESS using machine learning algorithms and deep neural networks with attention models. The medical records of 1,241 patients who examined polysomnography for insomnia or EDS were analyzed. All patients are classified into five groups according to the severity of insomnia and EDS. To develop the model, six machine learning algorithms were firstly applied. After going through normalization, the process with the CNN+ Attention model was applied. We classified a group with an accuracy of 93% even with only the results of 6 items (ISI1a, ISI1b, ISI3, ISI5, ESS4, ESS7). We simplified the sleep questionnaires with maintaining high accuracy by using machine learning models.

Longitudinal associations between pandemic post-traumatic stress symptoms and subsequent non-suicidal self-injury in adolescents: A multiple mediation model

BACKGROUNDS

PTSD is one of the most common conditions after people have experienced trauma. While previous studies have found a link between PTSD and non-suicidal self-injury, (NSSI), few studies have longitudinally explored this relationship and the underlying mechanisms.

AIMS

This study explored adolescent NSSI frequency after COVID-19 lockdown experiences, the relationship with early PTSD symptoms, and the mediating role of depression and sleep problems.

METHODS

A cohort of 1609 adolescents completed two surveys during and after the national lockdown in China; one month into the lockdown and six months later; which assessed demographic and pandemic-related exposure variables; PTSD, depression, sleep, and NSSI. Mediation analyses and hierarchical regression were employed to examine the relationships and the paths between these variables.

RESULTS

The NSSI rate was found to be 31.9 % after the three-month lockdown, with 20.6 % of adolescent participants reporting sleeping disorders, and 33.9 % indicating probable depression. Adolescents who had earlier PTSD symptoms, often smoked and/or drank, and had current depression and sleep disorders reported greater NSSI. Early PTSD symptoms were found to predict later NSSI and were mediated by sleep problems and depressive symptoms. Specifically, PTSD avoidance and numbing symptoms were significantly associated with NSSI above and beyond the depressive symptoms, sleeping problems, and the other covariables.

CONCLUSION

It is necessary to be vigilant about the increased risk of NSSI in adolescents who have experienced extended pandemic lockdowns. Preventing early adolescent PTSD symptoms, especially avoidance and numbness, and helping teenagers quit smoking and drinking could reduce the risk of sleep disorders, depression, and NSSI.

Insomnia Severity Index: A reliability generalisation meta-analysis

The aim of the current study was to conduct a reliability generalisation (RG) meta-analysis of Cronbach's alpha for the Insomnia Severity Index (ISI). A systematic search of three databases (PubMed, Scopus, and Web of Science) from inception to 12 March 2021 was performed. Publications that reported Cronbach's alpha for the total ISI score were included. Only psychometric-focussed studies were considered. Meta-analysis was carried out using a random-effects model to derive a pooled estimate of Cronbach's alphas. The number of participants in the included publications ranged from 25 to 12,056, with 33 studies (42 estimates) comprising internal consistency coefficients, and a combined sample size of N = 29,688. The age range of the included publications was from 13.4 to 74.3 years. Data extraction implied 33 publications out of 706 found through the database search. Cronbach's alphas ranged from 0.65 to 0.92. The majority of the reported coefficients were ≥0.7 and presented a low risk of bias (n = 32). The pooled alpha coefficient was 0.83 (IC [0.81-0.85]; SE = 0.009) with high heterogeneity among the included publications (I²  = 97%). Subgroup analyses including moderators such as continent, setting, risk of bias, and age did not affect significantly the overall result. In general, the cumulative estimate of Cronbach's alpha for the ISI is good. However, this finding should be interpreted with caution since there is a high heterogeneity level and some of the studies might not have checked the assumptions underlying Cronbach's alphas.

Cognitive and psychological factors associated with severe insomnia in Brazilian women: a cross-sectional study

Insomnia is the most prevalent sleep disorder in women. Sociodemographic, cognitive, and psychological factors may contribute to its severity. This study evaluated factors associated with severe insomnia in women with insomnia complaints. We evaluated 530 women aged 18-59 (mean = 40.5, SD = 10.2), who experienced insomnia complaints, using self-report instruments. Severe insomnia was defined as a score above 21 on the Insomnia Severity Index. Age, marital status, educational level, depression and anxiety, psychological inflexibility, and beliefs about sleep were assessed as potential factors associated with severe insomnia. Simple and multivariate analyses were conducted using binary logistic regression. Low education level (odds ratio; OR = 1.85 [1.27-2.69]), depression (OR = 2.17 [1.27-3.81]), psychological inflexibility (OR = 1.05 [1.02-1.08]), and dysfunctional beliefs about sleep (OR = 1.04 [1.02-1.06]) were factors associated with severe insomnia scores in the multiple logistic regression model. These findings are important from a public health perspective, because behavioral strategies designed to treat insomnia with a focus on cognitive and psychological factors are low-cost treatments and may help improve sleep quality in women, which also influences mental health.

Alexithymia and post-traumatic stress disorder symptoms in Chinese undergraduate students during the COVID-19 national lockdown: The mediating role of sleep problems and the moderating role of self-esteem

OBJECTIVE

This study examined whether sleep disturbance was a mediator between alexithymic traits and post-traumatic stress disorder (PTSD) COVID-19 pandemic-related stress symptoms, and explored whether self-esteem moderated the alexithymic contribution to poor sleep and PTSD symptoms.

METHOD

A representative sample of young adults (N = 2,485) from six universities in Southwest China completed online self-report surveys on alexithymia, sleep, PTSD, self-esteem, sociodemographic information, and health-related behaviors.

RESULTS

High alexithymic young adults were found to be more likely to have higher sleep problems and higher PTSD symptoms. The moderated mediation model showed that sleep problems mediated the associations between alexithymia and PTSD symptoms. Alexithymic people with lower self-esteem were more likely to have elevated PTSD symptoms and sleep problems than those with higher self-esteem.

CONCLUSION

Targeted psychological interventions for young people who have difficulty expressing and identifying emotions are recommended as these could assist in reducing their post-traumatic psychophysical and psychological problems. Improving self-esteem could also offer some protection for trauma-exposed individuals.

Emotional Dysregulation and Time Structure Mediate the Link between Perceived Stress and Insomnia among Unemployed Young People in China: A Cross-Sectional Study

In recent years, the problem of youth unemployment in China has become a great concern. Unemployed young people often find themselves under tremendous stress and vulnerable to sleep problems. The link between perceived stress and insomnia has been widely documented, but the potential mechanisms underlying this relationship have not been thoroughly revealed. The objective of this study was to examine the underlying mechanisms linking perceived stress to insomnia through testing the mediating effects of emotional dysregulation and time structure. Through a multiple-stage convenience sampling, 511 unemployed young people (38.6% women; mean age = 21.51; SD = 2.22) were measured using the 10-item Perceived Stress Scale (PSS-10), Insomnia Severity Index (ISI), 16-item Difficulties in Emotion Regulation Scale (DERS-16), and Time Structure Questionnaire (TSQ). Based on the statistical description of the sample, chi-squared tests, bivariate correlation analyses, and mediation analyses were performed. The study indicated that 53.0% (95% CI: 48.7-57.4%) of the participants reported probable insomnia, and both insomnia and perceived stress demonstrated strong associations with emotional dysregulation and time structure, which served as partial mediators between perceived stress and insomnia symptoms according to mediation analyses. Path analysis further revealed that, after controlling for age and gender, emotional dysregulation and time structure accounted for 31.8 and 17.6% of the effect of perceived stress on insomnia, respectively. This study provides empirical support for the association among perceived stress, emotional dysregulation, time structure, and insomnia symptoms. To improve the sleep quality and general wellbeing of unemployed young people, emotional dysregulation and time structure must be taken into consideration.

A Clinical Study on the Use of Yiqi Yangxue Decoction Combined with Chemotherapy to Promote Rapid Postoperative Recovery in Patients with Non-Small Cell Lung Cancer

Purpose. To observe the promotion effect of Yiqi Yangxue decoction combined with chemotherapy on the rapid recovery of non-small cell lung cancer (NSCLC) patients after surgery. Methods. Eighty postoperative NSCLC patients admitted to our hospital from April 2019 to September 2021 were divided into a chemotherapy group (n = 40) and a traditional Chinese medicine (TCM) group (n = 40) according to a random sampling method. Both groups were treated with surgery and postoperative routine chemotherapy. The TCM group was treated with Yiqi Yangxue decoction, one dose per day, starting from the first day of chemotherapy. Four weeks was a course of treatment, and three courses of treatment were taken continuously. The levels of serum tumour markers (carcinoembryonic antigen (CEA), cytokeratin 19 fragment (CYFRA21-1), carbohydrate antigen 125 (CA-125)), immune function indicators (CD3+, CD4+/CD8+, and NK cells), Pittsburgh Sleep Quality Index (PSQI) score, and Insomnia Severity Index (ISI) were compared between the two groups before and after treatment, and the clinical efficacy of the two groups was assessed with reference to the WHO efficacy criteria for solid tumours, and the toxic side effects of the two groups were assessed with reference to the WHO classification criteria for the toxic effects of chemotherapeutic drugs. Results. After treatment, the levels of CEA, CYFRA21-1, and CA-125 were lower than those before treatment in both groups, and they were lower in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the levels of CD3+, CD4+/CD8+, and NK cells in both groups were higher than before treatment, and they were higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the PSQI and ISI scores of both the groups were lower than those before treatment, and they were higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). After treatment, the overall tumour control rate was higher in the TCM group than in the chemotherapy group ( $P<0.05$ ). During the treatment period, the TCM group showed lower levels of gastrointestinal reactions, leucopenia, anaemia, and neurotoxicity than the chemotherapy group ( $P<0.05$ ). Conclusion. The combination of Yiqi Yangxue decoction combined with chemotherapy for postoperative NSCLC patients can effectively reduce serum tumour marker levels, enhance the body’s immune function and sleep quality, and the patient’s efficacy and toxicity reduction are obvious, which is conducive to the rapid recovery of many indicators after surgery.

Longing for sleep after violence: The impact of PTSD symptoms, avoidance, and pain on insomnia among female veterans

Women survivors of intimate partner violence often struggle with mental and physical problems that arise from incidents of violence. Beyond posttraumatic stress disorder (PTSD), the most common outcome, women also may suffer from debilitating chronic pain due to physical injuries sustained during particularly violent physical and/or sexual encounters. This may be a key interaction to explore as PTSD can lead to avoidance of distressing experiences, including chronic pain, resulting in enduring medical problems such as extreme sleep difficulties. This study aimed to identify if posttraumatic stress disorder (PTSD) symptoms from intimate partner violence (IPV) experiences had a conditional indirect effect on insomnia via chronic pain severity moderated by experiential avoidance among women. Female Veterans of at least 18 years of age completed online surveys at three timepoints (T1-T3) between 2014 and 2017 that included measures of PTSD, chronic pain, experiential avoidance, and insomnia. A total of 411 women participated in the initial survey at T1; 208 had a lifetime history of IPV experiences. The conditional indirect effect of PTSD symptoms (T1) on insomnia (T3) via chronic pain (T2) contingent upon experiential avoidance (T2) was also significant, demonstrating a significant moderated mediation model. This model was not significant for women without a history of IPV at T1. The findings indicate that women with IPV-related PTSD symptoms who are highly avoidant are more likely to experience chronic pain, leading to worse insomnia. Women without IPV experiences did not exhibit this same pattern. Findings have implications for improving trauma-focused treatment, approach coping strategies, pain management, and sleep interventions to address these deleterious psychological and medical issues.

Psychometric Properties of the Insomnia Severity Index Among Arabic Chronic Diseases Patients

Introduction

The Insomnia Severity Index (ISI) is a self-administrated questionnaire most frequently used to assess insomnia in clinical and non-clinical populations.

Objective

To evaluate the psychometric properties of the Arabic ISI among patients diagnosed with chronic diseases.

Methods

A cross-sectional and descriptive correlational design was used. A total of 1,005 patients with chronic diseases completed the seven items of the Arabic ISI version. The scale was assessed in terms of acceptability, internal consistency, and validity. Construct validity was explored with the use of principal factor analysis and confirmatory factor analysis, to examine the dimensional structure of the ISI.

Results

The Cronbach's alpha coefficient for the Arabic ISI was 0.82, which shows good reliability. The total ISI score did not have floor or ceiling effects. There was evidence of discriminate validity. The Principal Component Analysis (PCA) indicated two factors (four items loading on Factor I and three items loading on Factor II). The construct validity of PCA in terms of two factors was explored by confirmatory factor analysis to examine the dimensional structure of the ISI. The confirmatory factor analysis showed an absolute fit for the two-factor model.

Conclusion

The results support the two-factor structure of ISI. The Arabic version of the ISI demonstrated good reliability and validity for assessing insomnia in patients diagnosed with chronic diseases.

Prevalence of insomnia and insomnia symptoms following mild-traumatic brain injury: A systematic review and meta-analysis

Sleep is commonly disrupted following mild traumatic brain injury (mTBI), however there is a lack of consensus in the existing literature regarding the prevalence of insomnia/insomnia symptoms after injury. The aim of this review was to conduct a systematic review and meta-analysis of insomnia and insomnia symptoms' prevalence following mTBI. Full-text articles published in English in peer-reviewed journals, including adults with a clinical or self-reported mild traumatic brain injury diagnosis, were eligible for inclusion. Studies that assessed insomnia/insomnia symptoms after injury were included. Of the 2091 records identified, 20 studies were included in the review. 19 of these were meta-analysed (n = 95,195), indicating high heterogeneity among studies. Subgroup analyses indicated pooled prevalence estimates of post-mTBI insomnia disorder of 27.0% (95% CI 6.49-54.68) and insomnia symptoms of 71.7% (95% CI 60.31-81.85). The prevalence of insomnia is significantly higher in individuals who have sustained mild traumatic brain injury compared to prevalence estimates reported in the general population but high heterogeneity and methodological differences among studies make it difficult to provide reliable prevalence estimates. Future research should continue to advance our understanding of the onset, progression and impact of post-mild traumatic brain injury insomnia to promote the recovery and wellbeing of affected individuals. PROSPERO registration CRD42020168563.

Sleep Measurements in Women

Sleep in women and men have been studied in several studies with higher prevalence of sleep complaints in women compared with men. Several factors can affect sleep and could be argued to contribute to sex and gender differences in general sleep. There are no differences in guidelines when measuring sleep in women but several sleep assessment tools have been validated or compared between sexes. Because there is still a lack of knowledge on sleep measurements in women, the present review aimed to produce an overview of the current knowledge of objective and subjective sleep measurements in women.

Insomnia predicts treatment engagement and symptom change: a secondary analysis of a web-based CBT intervention for veterans with PTSD symptoms and hazardous alcohol use

Posttraumatic Stress Disorder (PTSD) and hazardous drinking are highly comorbid, and often more severe than PTSD or hazardous drinking alone. Integrated, web-based interventions for PTSD/hazardous drinking may increase access to care, but have demonstrated equivocal results in reducing PTSD and hazardous drinking. One factor that may explain treatment engagement and symptom change is the presence of insomnia symptoms. The current study conducted secondary data analysis of a randomized controlled trial of an integrated web-based intervention for PTSD symptoms and hazardous drinking to examine insomnia symptoms as predictors of PTSD symptoms, alcohol use, and treatment engagement. In the parent study, 162 veterans in primary care reporting PTSD symptoms and hazardous drinking were randomized to receive either the intervention or treatment as usual. The current study examined insomnia among veterans who received the intervention (n = 81). Regression models tested baseline insomnia symptoms as predictors of treatment engagement, follow-up PTSD symptoms, and alcohol use. Hierarchical regression models tested change in insomnia during treatment as a predictor of follow-up PTSD symptoms and alcohol use. Results showed baseline insomnia predicted treatment engagement and follow-up drinking days, but not PTSD symptoms or heavy drinking days. Although overall change in insomnia was small, it predicted follow-up PTSD and heavy drinking days, but not drinking days. Results are consistent with previous research highlighting the importance of identifying and treating insomnia in the course of integrated treatment for PTSD/hazardous drinking. Future research should investigate how to best integrate insomnia, PTSD, and/or hazardous drinking interventions to maximize treatment engagement.

Correlates of sleep disturbance in Veterans with traumatic brain injury and chronic pain: A cross-sectional study

BACKGROUND

Few studies have investigated sleep in Veterans with comorbid traumatic brain injury (TBI) and chronic pain.

OBJECTIVE

To describe mood and cognitive correlates with sleep disturbance in a sample of Veterans with both TBI and chronic pain.

RESEARCH METHOD

Cross-sectional, correlational analyses were completed using baseline data from a randomized controlled trial comparing psychosocial treatments for pain in Veterans with TBI. Enrollment occurred between July 2015 and January 2017. Self-report measures of hours slept, insomnia severity, depression and PTSD symptoms were collected along with a brief neuropsychological assessment.

RESULTS

Participants (n = 221) were an average age of 37.2 years (SD = 8.2) and mostly male (89%). Participants reported sleeping an average of 4.9 h a night (SD = 1.4) with an average Insomnia Severity Index (ISI) score of 17.4 (SD = 5.4) suggesting moderate insomnia symptoms. Fewer hours slept was associated with higher depression scores (r = -0.28, p < 0.001) and slower processing speed (r = 0.23, p < 0.001). Increasing insomnia severity was associated with greater depression (r = 0.57, p < 0.001) and PTSD symptoms (r = 0.44, p < 0.001), and slower processing speed (r = -0.22, p < 0.001).

CONCLUSIONS

The average ISI score was above the clinical cut off for insomnia diagnosis. Results suggest that those with more severe insomnia symptoms report higher depression and PTSD symptoms as well as exhibit slower processing speed. Improving sleep in this population may be important for improving outcome following TBI.

Structural validity of the Insomnia Severity Index: A systematic review and meta-analysis

The factor structure of the Insomnia Severity Index (ISI) is discussed, with examples being drawn from about 13 disparate reported models. A systematic appraisal of procedural details of studies investigating the dimensionality of the ISI was performed. The databases CINAHL, Cochrane Library, Embase, Medline, and PsycINFO were searched thoroughly, and all articles in English, published, and/or available online as of 14th March 2019, were included. Meta-analyses of Cronbach's alpha and structural validity measures were performed. Several inadequacies or omissions were found in analyses using the three groups of measures. Fifteen out of 20 studies did not employ either EFA or CFA, 10 studies did not report CFA, while five did not report EFA. The most common omissions related to multivariate normality, final model selection based on consideration of fit indices, parsimony, and failure to consider the theoretical construct in the final model selection. Meta-analysis showed that CFA outcome is more robust compared to EFA, two-factor solution is the vigorous presentation of dimensionality compared to a three-factor solution, and ISI has a high pooled Cronbach's alpha. Further validation of the disparate models of the ISI is needed with more comprehensive reporting guidelines, such as the one suggested in the present review.

A population-based psychometric analysis of the insomnia severity index in black women with and without a history of cancer

Black women are under-represented in insomnia research. Further, cancer treatments increase the risk of late effects, thus affecting the sleep of psychologically and medically vulnerable cancer survivors. The Insomnia Severity Index (ISI) is widely used, but has not been researched in black women, and research in cancer survivors is limited. Prior studies demonstrate that psychometric properties of the ISI are not consistent across samples. This study examined the internal consistency and factor structure of the ISI in 29,500 participants from the Black Women's Health Study, an epidemiological study of black women in the United States. This cohort included 28,214 women without a cancer history and 1,286 cancer survivors. Exploratory, confirmatory and multigroup analyses were conducted to determine the psychometric properties of the ISI in these groups. The mean ISI score was 7.18 (standard deviation [SD] = 6.82). Findings supported the internal consistency reliability of the ISI in black women with (Ω = 0.896) and without (Ω = 0.892) a cancer history. Exploratory factor analyses supported a one-factor structure. Confirmatory factor analyses indicated that fit of this one-factor model was not robust in survivors (Satorra-Bentler chi-square [χSB² (14)] = 197.78, comparative fit index [CFI] = 0.928, root mean-square error of approximation [RMSEA] = 0.143) or in women with no cancer history (χSB² (14) = 2,887.93, CFI = 0.945, RMSEA = 0.121), but the alternative models we examined were not superior. Although factor structures in previous studies have varied considerably, we found a one-factor structure. Although internal consistency reliability was strong, factor analytic results did not further support the ISI. Inconsistencies in ISI measurement properties across studies may reflect differences in sample sizes and populations.

Prevalence, risk correlates, and health comorbidities of insomnia in US military veterans: results from the 2019-2020 National Health and Resilience in Veterans Study

STUDY OBJECTIVES

Veterans experience high levels of trauma, psychiatric, and medical conditions that may increase their risk for insomnia. To date, however, no known study has examined the prevalence, risk correlates, and comorbidities of insomnia in a nationally representative sample of veterans.

METHODS

A nationally representative sample of 4,069 US military veterans completed a survey assessing insomnia severity; military, trauma, medical, and psychiatric histories; and health and psychosocial functioning. Multivariable analyses examined the association between insomnia severity, psychiatric and medical comorbidities, suicidality, and functioning.

RESULTS

A total of 11.4% of veterans screened positive for clinical insomnia and 26.0% for subthreshold insomnia. Greater age and retirement were associated with a lower likelihood of insomnia. Adverse childhood experiences, traumatic life events, lower education and income were associated with greater risk for insomnia. A "dose-response" association was observed for health comorbidities, with increasing levels of insomnia associated with elevated odds of psychiatric and medical conditions (clinical vs no insomnia odds ratio = 1.8-13.4) and greater reductions in health and psychosocial functioning (clinical vs no insomnia Cohen's d = 0.2-0.4). The prevalence of current suicidal ideation was 3-5 times higher in veterans with clinical and subthreshold insomnia relative to those without insomnia (23.9% and 13.6% vs 4.5%, respectively).

CONCLUSIONS

Nearly 2 in 5 US veterans experience clinical or subthreshold insomnia, which is associated with substantial health burden and independent risk for suicidal ideation. Results underscore the importance of assessment, monitoring, and treatment of insomnia in veterans as they transition from the military.

The Development of a Brief Version of the Insomnia Severity Index (ISI-3) in Older Adult Veterans with Posttraumatic Stress Disorder

Objective/Background: The Insomnia Severity Index (ISI) is an insomnia self-report measure used to identify individuals at risk for insomnia disorder. Although the full ISI is only seven questions, a briefer version would allow more efficient and pragmatic administration in routine practice settings. Reliable and valid brief measures can support measurement-based care. The present study was a proof-of-concept study that developed a brief version of the ISI, the ISI-3, in a sample of older adult veterans with posttraumatic stress disorder (PTSD), a group which is at increased risk for insomnia.Patients/Methods: Participants included 86 older veterans with combat- or military-related PTSD. Veterans completed a clinician-administered PTSD diagnostic interview, self-report measures of insomnia and other psychosocial questionnaires, and two neuropsychological assessments. The factor structure of the ISI was examined to reduce the measure into a brief version. The reliability and validity of the ISI-3 were examined.Results: Principal axis factoring yielded a one-factor solution, which reproduced 59% of the item variance. Item reduction procedures resulted in three items, which best represented this factor ("Insomnia Impact;" ISI-3). For the ISI-3, internal consistency was good (α =.89). Convergent validity was demonstrated via moderate to high positive correlations between the ISI-3 and other measures of sleep disturbance. Divergent validity was demonstrated via non-significant correlations between the ISI-3 and unrelated measures and moderate correlations with self-reported depression.Conclusions: The ISI-3 is a psychometrically valid brief version of the ISI. Clinicians can administer the ISI-3 to screen for insomnia and monitor changes in insomnia during treatment.

Measuring Subjective Sleep Quality: A Review

Sleep quality is an important clinical construct since it is increasingly common for people to complain about poor sleep quality and its impact on daytime functioning. Moreover, poor sleep quality can be an important symptom of many sleep and medical disorders. However, objective measures of sleep quality, such as polysomnography, are not readily available to most clinicians in their daily routine, and are expensive, time-consuming, and impractical for epidemiological and research studies., Several self-report questionnaires have, however, been developed. The present review aims to address their psychometric properties, construct validity, and factorial structure while presenting, comparing, and discussing the measurement properties of these sleep quality questionnaires. A systematic literature search, from 2008 to 2020, was performed using the electronic databases PubMed and Scopus, with predefined search terms. In total, 49 articles were analyzed from the 5734 articles found. The psychometric properties and factor structure of the following are reported: Pittsburgh Sleep Quality Index (PSQI), Athens Insomnia Scale (AIS), Insomnia Severity Index (ISI), Mini-Sleep Questionnaire (MSQ), Jenkins Sleep Scale (JSS), Leeds Sleep Evaluation Questionnaire (LSEQ), SLEEP-50 Questionnaire, and Epworth Sleepiness Scale (ESS). As the most frequently used subjective measurement of sleep quality, the PSQI reported good internal reliability and validity; however, different factorial structures were found in a variety of samples, casting doubt on the usefulness of total score in detecting poor and good sleepers. The sleep disorder scales (AIS, ISI, MSQ, JSS, LSEQ and SLEEP-50) reported good psychometric properties; nevertheless, AIS and ISI reported a variety of factorial models whereas LSEQ and SLEEP-50 appeared to be less useful for epidemiological and research settings due to the length of the questionnaires and their scoring. The MSQ and JSS seemed to be inexpensive and easy to administer, complete, and score, but further validation studies are needed. Finally, the ESS had good internal consistency and construct validity, while the main challenges were in its factorial structure, known-group difference and estimation of reliable cut-offs. Overall, the self-report questionnaires assessing sleep quality from different perspectives have good psychometric properties, with high internal consistency and test-retest reliability, as well as convergent/divergent validity with sleep, psychological, and socio-demographic variables. However, a clear definition of the factor model underlying the tools is recommended and reliable cut-off values should be indicated in order for clinicians to discriminate poor and good sleepers.

Satisfaction with Life after Mild Traumatic Brain Injury: A TRACK-TBI Study

Identifying the principal determinants of life satisfaction following mild TBI (mTBI) may inform efforts to improve subjective well-being in this population. We examined life satisfaction among participants in the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study who presented with mTBI (Glasgow Coma Scale [GCS] score = 13-15; n = 1152). An L1-regularization path algorithm was used to select optimal sets of baseline and concurrent symptom measures for prediction of scores on the Satisfaction with Life Scale (SWLS) at 2 weeks and 3, 6, and 12 months post-injury. Multi-variable linear regression models (all n = 744-894) were then fit to evaluate associations between the empirically selected predictors and SWLS scores at each follow-up visit. Results indicated that emotional post-TBI symptoms (all b = -1.27 to -0.77, all p < 0.05), anhedonia (all b = -1.59 to -1.08, all p < 0.01), and pain interference (all b = -1.38 to -0.89, all p < 0.001) contributed to the prediction of lower SWLS scores at all follow-ups. Insomnia predicted lower SWLS scores at 2 weeks, 3 months, and 6 months (all b = -1.11 to -0.83, all ps < 0.01); and negative affect predicted lower SWLS scores at 2 weeks, 3 months, and 12 months (all b = -1.38 to -0.80, all p < 0.005). Other post-TBI symptom domains and baseline socio-demographic, injury-related, and clinical characteristics did not emerge as robust predictors of SWLS scores during the year after mTBI. Efforts to improve satisfaction with life following mTBI may benefit from a focus on the detection and treatment of affective symptoms, pain, and insomnia. The results reinforce the need for tailoring of evidence-based treatments for these conditions to maximize efficacy in patients with mTBI.

Greater Severity and Functional Impact of Post-traumatic Headache in Veterans With Comorbid Neck Pain Following Traumatic Brain Injury

BACKGROUND

Post-traumatic headache (PTH) is a commonly experienced symptom after mild traumatic brain injury (mTBI). Blast injury- or blunt injury-related mechanisms for mTBI in veterans can also affect musculoskeletal structures in the neck, resulting in comorbid neck pain (NP). However, it is unknown whether the presence of comorbid NP may be associated with a different pattern of headache symptoms, physical functioning, or emotional functioning compared to those without comorbid NP. The purpose of this study is to examine the role of comorbid NP in veterans with mTBI and PTH.

DESIGN AND METHODS

This was a cross-sectional investigation of an existing dataset that included 33 veterans who met inclusion criteria for PTH after mTBI. Standardized measures of headache severity and frequency, insomnia, fatigue, mood disorders, and physical and emotional role function were compared between groups with and without comorbid NP.

RESULTS

The majority of participants with PTH reported comorbid NP (n = 22/33, 67%). Those with comorbid NP experienced more headache symptoms that were severe or incapacitating, as compared to mild or moderate for those without NP (φ = 0.343, P = .049); however, no differences in headache frequency (φ = 0.231, P = .231) or duration (φ = 0.129, P = .712) were observed. Participants with comorbid NP also reported greater insomnia (d = 1.16, P = .003) and fatigue (d = 0.868, P = .040) as well as lower physical functioning (d = 0.802, P = .036) and greater bodily pain (d = 0.762, P = .012). There were no differences in anxiety, depression, mental health, emotional role limitations, vitality, or social functioning between those with and without comorbid NP (d ≤ 0.656, P ≥ .079).

CONCLUSIONS

A majority of veterans with mTBI and PTH in our sample reported comorbid NP that was associated with greater headache symptom severity and physical limitations, but not with mood or emotional limitations. Preliminary findings from this small convenience sample indicate that routine assessment of comorbid NP and associated physical limitations should be considered in veterans with mTBI and PTH.

Development of a Practice Tool for Primary Care Providers: Medication Management of Posttraumatic Stress Disorder in Veterans with Mild Traumatic Brain Injury

Posttraumatic stress disorder (PTSD) and comorbid mild traumatic brain injury (mTBI) are highly prevalent in veterans who served in Iraq [Operation Iraqi Freedom/Operation New Dawn] and Afghanistan [Operation Enduring Freedom]. Complicated psychotropic medications are used for treatment of PTSD and comorbid mTBI symptoms lead to polypharmacy related complications. Primary care providers (PCPs) working in Community Based Outpatient Clinics (CBOCs) are usually burdened with the responsibility of managing this complicated medication regimen or relevant side effects. The PCPs do not feel equipped to provide this complicated psychopharmacological management. Thus, there is a need for a comprehensive yet concise tool for the medication management of PTSD in veterans with comorbid mTBI. (1) To conduct focus groups of interdisciplinary team of experts and other stake holders to assess need, (2) To carefully review current VA/Department of Defense practice guideline to identify content, (3) To develop an evidence based, user friendly, and concise pocket guide for the PCP's. Content was identified by review of current guidelines and available literature and was finalized after input from stakeholders, multidisciplinary team of experts, and review of qualitative data from focus groups/interviews of clinicians working in remote CBOCs. The pocket tool was formatted and designed by multimedia service. A pocket guide in the form of a bi-fold, 4″ × 5.5″ laminated card was developed. One thousand hard copies were distributed in the local VA medical center. This product is available online for download at the South-Central Mental Illness Research, Education, and Clinical Center website ( https://www.mirecc.va.gov/VISN16/ptsd-and-mtbi-pocket-card.asp ). This pocket card provides PCPs an easy to carry and user-friendly clinical decision-making tool to effectively treat veterans with PTSD and comorbid mTBI.

Quetiapine augmentation of prolonged exposure therapy in veterans with PTSD and a history of mild traumatic brain injury: design and methodology of a pilot study

BACKGROUND

Selective serotonergic reuptake inhibitors (SSRIs) are first-line pharmacologic treatments for patients with posttraumatic stress disorder (PTSD), but must be given over extended period of time before the onset of action. The use of SSRIs in PTSD patients with mild traumatic brain injury (mTBI) is problematic since SSRIs could exacerbate post-concussion syndrome (PCS) symptoms. VA/DOD guidelines identify trauma-focused psychotherapy as the best evidence-based treatment for PTSD, but overall effectiveness is limited by reduced levels of patient engagement and retention. A previous study from this research group suggested that quetiapine monotherapy, but not risperidone or valproate, could increase engagement in trauma-focused psychotherapy.

METHODS

We report the study protocol of a pilot study funded under the South-Central Mental Illness Research, Education, and Clinical Center pilot study program from the U.S. Department of Veterans Affairs. This randomized, open-label study was designed to evaluate the feasibility of completing a randomized trial of quetiapine vs. treatment as usual to promote patient engagement in PTSD patients with a history of mTBI.

DISCUSSION

We expect that the success of this ongoing study should provide us with the preliminary data necessary to design a full-scale randomized trial. Positive efficacy results in a full- scale trial should inform new VA guidelines for clinical practice by showing that quetiapine-related improvements in patient engagement and retention may be the most effective approach to assure that VA resources achieve the best possible outcome for veterans.

TRIAL REGISTRATION

NCT04280965 .

The Sensor Technology and Rehabilitative Timing (START) Protocol: A Randomized Controlled Trial for the Rehabilitation of Mild Traumatic Brain Injury

BACKGROUND

Clinical practice for rehabilitation after mild traumatic brain injury (mTBI) is variable, and guidance on when to initiate physical therapy is lacking. Wearable sensor technology may aid clinical assessment, performance monitoring, and exercise adherence, potentially improving rehabilitation outcomes during unsupervised home exercise programs.

OBJECTIVE

The objectives of this study were to: (1) determine whether initiating rehabilitation earlier than typical will improve outcomes after mTBI, and (2) examine whether using wearable sensors during a home-exercise program will improve outcomes in participants with mTBI.

DESIGN

This was a randomized controlled trial.

SETTING

This study will take place within an academic hospital setting at Oregon Health & Science University and Veterans Affairs Portland Health Care System, and in the home environment.

PARTICIPANTS

This study will include 160 individuals with mTBI.

INTERVENTION

The early intervention group (n = 80) will receive one-on-one physical therapy 8 times over 6 weeks and complete daily home exercises. The standard care group (n = 80) will complete the same intervention after a 6- to 8-week wait period. One-half of each group will receive wearable sensors for therapist monitoring of patient adherence and quality of movements during their home exercise program.

MEASUREMENTS

The primary outcome measure will be the Dizziness Handicap Inventory score. Secondary outcome measures will include symptomatology, static and dynamic postural control, central sensorimotor integration posturography, and vestibular-ocular-motor function.

LIMITATIONS

Potential limitations include variable onset of care, a wide range of ages, possible low adherence and/or withdrawal from the study in the standard of care group, and low Dizziness Handicap Inventory scores effecting ceiling for change after rehabilitation.

CONCLUSIONS

If initiating rehabilitation earlier improves primary and secondary outcomes post-mTBI, this could help shape current clinical care guidelines for rehabilitation. Additionally, using wearable sensors to monitor performance and adherence may improve home exercise outcomes.

Psychometric properties of the Insomnia Severity Index in cancer survivors

OBJECTIVE

Insomnia is commonly associated with cancer treatment. Cancer treatments increase risk for numerous psychological and medical late effects, thus making cancer survivors psychologically and medically vulnerable. Prior research examined psychometric properties of the Insomnia Severity Index (ISI) with various populations, including the French version of the ISI, with participants undergoing active cancer treatment. However, no prior studies examined insomnia exclusively with cancer survivors, using the English version of the ISI.

METHODS

This study examined internal consistency and factor structure of an English version of the ISI in 100 cancer survivors (M_age  = 51.1; SD = 14.92). This final analytic sample was composed of participants from three different insomnia interventions. Survivors ranged from less than 1 year off treatment (17%) to 21+ years off treatment (6%), with most participants off treatment for 1 to 2 years (24%).

RESULTS

The mean ISI score for the total sample was 16.69 (SD = 4.47), indicating clinical insomnia, with moderate severity. Principal Components Analysis (PCA) indicated two factors (five items loading on Factor I and two items loading on Factor II) and acceptable reliability (α = .73). Item-total correlations ranged from .15 to .63.

CONCLUSIONS

Findings support the reliability of the ISI in cancer survivors. However, its factor structure warrants additional research with larger samples of cancer survivors. Results suggest inconsistency across participant responses and that ISI items may be functioning differently with this unique population of cancer survivors. Findings indicate that sleep maintenance problems are central to the experience of insomnia in our survivor sample.